The most useful electronic health records strike a good balance between structured data and physicians' free-text narrative, but such balance can be hard to achieve, according to experts, American Medical News reports.
Lesley Kadlec -- director of the American Health Information Management Association's HIM Practice Excellence -- said that EHR templates help doctors capture data more accurately and efficiently, but they do not always support good documentation, resulting in a loss of physician dictation.
Dictation can include information such as the doctor's:
- Thought process;
- Reasoning behind decisions; and
- "If/then" statements that could guide decision making.
According to Brian Yeaman of Norman Regional Health System in Oklahoma, dictation is "valuable to the consultants, to the other physicians caring for that patient and to the nurses who are trying to manage that patient's care when the doctor is not physically seeing them."
Experts -- including Kadlec and Yeaman -- recommend that doctors work to strike the right balance between structured and narrative data by:
- Taking advantage of EHRs' free-text fields outside the template; and
- Using speech recognition technology that captures the dictated note and creates a text narrative.
Yeaman explained that speech recognition technology could be used with clinical language processing to identify text that could be converted into structured data.
However, some experts -- such as Albert Lai, an assistant professor at The Ohio State University College of Medicine -- said such tools should be routinely audited for accuracy (Lewis Dolan, American Medical News, 8/19).